Written by: Yaffa Liebermann, PT,GCS,CEO
1991-1992 Outpatient at the Jersey Shore
The Outpatient facility that I worked in provided treatment to patients who were mostly referred by orthopedic doctors. Many of the injuries were sports related however their ages varied which allowed me to learn and provide services to both young and old.
Treating a young man versus older man: There is a difference in the treatment approaches for the same injury when occurring in a teenager as opposed to an older person. A teenager’s ankle injury can be treated much more aggressively with stretching exercises followed by closed kinetic chain exercises and mechanical resistive exercise.
Balance activities can be taken to a high-level performance like standing on the toes of one leg while kicking a ball with the other leg. However, the same injury, when occurring in an older adult, may be treated through the same principles but not as aggressively.
Non-discrimination policy: We have two legs, two arms, one head and one trunk. Each body has a right and left side, front and back. If an injury occurs on only one side, in treatment session both sides will still receive treatment. The good side will send over a flow of energy to the injured side with feedback to perform the correct motion. The therapist should instruct the patient on how to put equal weight bearing on both feet and equally use the left and right hands. By paying attention to this equal distribution of workload on the injured body, the therapist is teaching the patient correct movement to the body as one unit.
Mobile versus stable action = dynamic versus static kinesthetic = concentric versus eccentric muscle movement = open versus closed kinetic chain exercises: Each muscle and joint of the body work in our daily activities in various positions. Each muscle and joint is being challenged to perform in a different range, strength and weight bearing. Example: The right Hip Abductor works in standing as a prime mover to lift the leg to the right side. The mobility of the right abductor would be in concentric muscle action. Then the right hip is acting as a stabilizing component when lifting the left leg off the ground; its action is in the eccentric lengthening of the muscle range. As therapists, our goal is to train the patient’s right hip abductor in all the positions, ranges and strength needed for daily activity.
Intervention for pain management:
Pain and weakness are typically a large reason to seek a PT and/or OT treatment. Pain can create a vicious cycle of depression, tension, and musculoskeletal problems, which leads to a functional decline. It can be exacerbated by muscle imbalance, poor posture, poor mechanics, and lifestyle issues. Evaluation and treatment by physical and occupational therapists have to be in conjunction with a multidisciplinary approach by all caregivers toward the patient. The physical therapists assess pain using different techniques depending on the client’s status.
The Cycle of Pain
Evaluation of a client that is alert and oriented should include a description of: *Location of the pain. *Intensity (scale of 0-10). * Duration (how long related to movement). *Frequency (constant or intermittent). * Type (sharp or dull) .*Pain related to ADL and gait analysis. *Postural changes causing pain. * Limitation of joint movement causing pain. * Muscle strength/weakness.*Muscle tone causing contractures.
If the patient’s cognitive status is impaired the therapist should look for the following indicators: *Facial expressions. * Vocalizations. *Body movements.*Interpersonal interaction changes.*Activity pattern changes. *Mental status changes.
PT/OT Intervention- Therapeutic Exercises: Are the most important part of the healing process of the body in order to help it recover from any pain or insult. The movement and the mobility will break the cycle of pain and create a path in the body for the healing process to start its journey.
Exercises include: *Passive range of motion: stretching of tight muscles and joints.*Active assistive range of motion *Active range of motion. *Progressive resistive exercise ― strengthening exercises.*Balance training.*Gait training to avoid pain.*Postural correction and reeducation. *Assistive devices, splints or braces
Posture: Posture promotes movement efficiency and endurance and contributes to an overall feeling of wellbeing. Poor posture may cause fatigue, muscular strain, and, in later stages, pain. Many individuals with chronic back pain can trace their problems to years of poor postural habits.
Ergonomics: Ergonomics refers to the relationships among the patient, the tasks, the activities and the environment in which the patient functions. Ergonomics uses scientific and engineering principles to improve the safety, efficiency, and quality of movement in both static and dynamic position.
The Examination: Has three components: the patient/client history, the systems review, tests and measures. Injury/illness refers to the occurrence of movement-related pathology, pain, impairment, or loss of function. An Occupational Therapist participates as a team member in an effort for integrated injury/illness prevention and ergonomics in the patient’s environment.
PT/OT Intervention– Manual Therapy:
Mobilization and manipulation of the joints: The mobilization technique affects the proprioceptors nerve endings in the joints by the oscillation that decreases the pain and therefore increases the mobility of the joint.
- Reflexology ― reflex zone therapy of the feet: Reflex zone therapy of the feet is a manual discipline, which takes place on the feet but is not a foot massage.
- Craniosacral therapy: CST is a gentle, hands-on method of evaluating and enhancing the functioning of a physiological body system called the CranioSacral system ― composed of the membranes and cerebrospinal fluid that surrounds and protects the brain and spinal cord.
- Myofascial release: Myofascial release consists of a gentle pressure applied in the direction of the fascia restriction. At first, the elastic component of the fascia will release, and at some point in time, the collagenous barrier will be engaged. This barrier cannot be forced (it is too strong). One waits with gentle pressure, and as the collagenous aspect releases, the PT follows the motion of the tissue, barrier upon barrier until freedom is felt.
- Massage: Massage is gentle or vigorous strokes on the bulk of the muscles that end with delivering the lymphatic fluid with its waste products into the lymphatic system.
PT Intervention– Modalities: Safety precautions:
Special considerations are necessary to ensure safety of the elderly patient when using specific conservative treatment interventions. The patient should have adequate sensation of temperature and pain in the area being treated to provide feedback to the therapist. The body region being treated must have peripheral sensory input, like light touch for electrode placement of TENS.
TENS – Transcutaneous Electrical Nerve Stimulation: Electrical stimulation is the application of an electrical current to the body via transcutaneous electrodes for therapeutic benefit. It works primarily by stimulating peripheral nerves to produce action potentials, which are then transmitted along these nerves.
Iontophoresis: Iontophoresis is the introduction of substances into the body for therapeutic purposes by means of a direct current.
Ultrasound: Therapeutic ultrasound generally has a frequency of between 1 and 3 MHz (millions of cycles/second) to achieve a depth of penetration through soft tissue of between 1 and 5 cm (with 1MHz penetrating deeper than 3 MHz).
Diathermy: Three types of diathermy have been used in rehabilitation: microwave, shortwave and long wave, with each being named for its position in the radio frequency continuum. In general, the longer the wavelength, the deeper the depth of penetration of therapeutic heat.
Short-wave Diathermy: The concept of producing heat deep within the tissues, beyond the reach of infrared, hot packs, and other forms of superficial heat, is appreciated by clinicians and, where applicable, has proven effective through the years.
Infrared: Infrared will be absorbed by the top 3 mm of tissues and that will result in increased circulation, a sedative effect on superficial nerve endings, lowering of blood pressure, increased respiration and perspiration, loss of salt, water, urea, and other nitrogenous substances, and a general increase in reticuloendothelial activity. Infrared Nonluminous penetration:2-5 mm; Infrared Luminous: 5mm to 1 cm.
Cold Laser – Light Amplification by Stimulated Emission of Radiation: The laser is used for analgesic purposes; the beam is generally directed at acupuncture points, trigger points, and nerve roots. At acupuncture and trigger points, nerve roots, and pain sites, a dosage of 15 to 30 seconds for each point is recommended.
Hot packs: Heat packs deliver high-temperature moist heat that stimulates circulation, relieves pain and stiffness, and relaxes muscle spasms or tension. Heat packs stimulate tissue activity with deep, penetrating heat and temporary pain relief results in a matter of minutes. Penetrate to: 2-5 mm.
Paraffin wax therapy: Warm, soothing paraffin surrounds the skin with penetrating heat that increases circulation, dramatically softens skin, and makes wrinkles and fine lines virtually disappear. Paraffin treatments soothe aches and pains due to arthritis, joint stiffness, sport injury, or over-use. Penetrate to 2-5 mm.
Aquatic therapy: Although it is not often used for acute cases, aquatic therapy can be a useful resource for patients with chronic pain conditions, or patients who are having difficulty functioning on land. The benefit of performing treatments in the pool is a reduction in weight bearing, and a safe atmosphere to work on any balance issues.
Ice packs: Ice is used after an injury to reduce swelling and decrease pain. Ice constricts the blood vessels in the treated areas, which restricts an overflow of fluids into that area. When the ice pack is removed after ten minutes, the blood vessels dilate bringing fresh blood into the area. Penetrate 5mm to 4cm.
Splinting: If pain develops in a joint or a muscle during a functional movement or at rest, the therapist should evaluate the patient’s appropriateness for a splint. Usually splinting would be applied for a short time during acute pain to reduce the stress of the joint and to relax the muscle.
Case presentation: A patient who suffers from lumbar pain and cannot sit for more than one minute, even to enjoy a hot meal, is referred for physical therapy treatment. The physical therapist thoroughly evaluates the patient by getting the patient’s history, listening to the patient’s description of pain, and assessing the patient’s muscle and balance capabilities, according to the findings.
The physical therapist then proceeds with choices of the following treatment: 1) Hot/ice packs to the lower back, as preferred by the patient. 2) Apply ice packs for 10 minutes. 3) Apply hot packs for 15 – 20 minutes. 4) Massage the patient’s back until the protective muscle spasm decreases. 5) Mobilization grade I+II to decrease the pain. 6) Ultrasound or Electrical Stimulation application to the painful area. 7) Stretching exercises, followed by active exercise first by the back muscles, then the legs and arms. 8) The patient’s ergonomics in his work or home are evaluated. 9) Illustrated home exercise program is provided to the patient after practicing with him/her. 10) Education for continuing correct positioning and performing home exercises.
It was fun and challenging to work in an outpatient clinic. The patient and therapist developed good relationship. Patients complimented other patients and shared jokes and stories while progressing toward their individual goals.
More to come.